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Gwen - GI and General surgery > GI: Anorectal disorders > Flashcards

GI: Anorectal disorders Flashcards

1
Q

What is pruritis ani?

A

Itch that occurs around the anus

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2
Q

What can cause pruritis ani?

A
  • Moist/solied anus
  • Fissures
  • Incontinence
  • Poor hygeine
  • Tight pants
  • Threadworm
  • Fistula
  • Dermatoses
  • Lichen sclerosis
  • Anxiety
  • Contact dermatitis
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3
Q

How would you treat someone with pruritis ani?

A
  • Avoid scratching
  • Improve perianal hygeine
  • Avoid foods which loosen stool
  • Soothing ointment
  • Topical steroids (max 2 weeks)
  • Oral antihistamine
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4
Q

What are anal fissures?

A

Painful tears in the squamous lining of the lower anal canal. Often, if chronic, they will have a sentinal pile or mucosal tag at the external aspect

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5
Q

What sex do anal fissures occur more commonly in?

A

Males

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6
Q

What are causes/predisposing features of anal fissures?

A
  • Hard stools - most common
  • IBD esp crohns
  • Constipation
  • Syphillis
  • Herpes
  • Trauma
  • Anal cancer
  • Psoriasis
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7
Q

Rsk factors of anal fissure

A

Constipation

Dehydration

Inflammatory bowel disease

Chronic diarrhoea

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8
Q

Prsesentation of anal fissure

A

90% in posterior midline (anterior more common following birth)

  • PAINFUL bleeding post defication
    • “like passing broken glass
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9
Q

Why do anal fissures take a significant amount of time to heal?

A

Spasm around the area leads to relative ischaemia, meaning that fissures take longer to heal

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10
Q

What might you consider doing in someone with anal fissures if you suspected a sinister cause?

A

Proctoscopy/Sigmoidoscopy

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11
Q

How would you manage someone with anal fissures?

A
  • Dietary fibre
  • Fluids
  • Stool softener
  • Hygeine advice
  • Consider medical
    • Topical 5% lidocaine + 0.2% GTN Paste (
    • Topical 2% Diltiazem
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12
Q

What medical treatment can be used to treat anal fissures?

A
  • Topical 5% lidocaine + 0.2% GTN Paste
    • GTN ointment relaxes internal sphincter by increasing blood supply
  • Topical 2% Diltiazem
    • A CCB relaxes internal sphincter by preventing spasm
  • Botulinium toxin
    • Relaxes internal sphincter, lasts for 2 months.
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13
Q

What would you consider dioing in a patient with anal fissures where conservative and medical management has failed?

A

Sirgical management

Lateral partial internal sphinterectomy

Indicated if conservtive measures fail or chronic fissure - incontinence

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14
Q

What is a anorectal abscess?

A

Abscess which is usually caused by gut bacteria, which can occur in the perianal, ischiorectal, intersphincteric or supralevator regions

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15
Q

Predisposing factors to ano-rectal abscess

A

CD

DM

Malignancy

Immunosupression

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16
Q

What is thought to cause ano-rectal abscess

A

Thought to b plugging of anal ducts (which drain anal glands). Blockage of these ducts cause stasis of bacteria

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17
Q

Presentation anorectal abscess

A

Pain +/- localised severe itching/discharge

Wrose on sitting down

Systemic features in severe eg feature

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18
Q

Typical bacteria anorectal abscess

A

E. Coli

Enterococcus

Bacteriods

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19
Q

How would you manage a perianal abscess?

A

Incise and drain under GA

Antibiotics

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20
Q

What diseases are perianal abscesses associated with?

A
  • Diabetes mellitus
  • Crohn’s
  • Malignancy
  • Fistulae
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21
Q

What is a fistula in ano?

A

A track communicating between the skin and anal canal/rectum. Often occurs following the development of an abscess

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22
Q

How do fistulae in ano form?

A

Blockage of deep intramuscular gland ducts thought to predispose to the formation of abscesses, which discharge to form fistulas

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23
Q

What are causes of fistula-in-ano?

A
  • Perianal disease (majority)
  • Abscesses
  • Crohn’s Disease
  • TB
  • Diverticular disease
  • Rectal carcinoma
  • Immunocompromise
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24
Q

What is goodall’s rule?

A

Predicts trajectory of fistula depending on location

If anterior it tracts in a straight line

If posterior the internal opening is at the 6 oclock position ( curved)

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25
Q

Presentation of anal fistula

A

Pain - throbbing and constant

Perianal dishcarge (blood and pus) - as a result of associated infection

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26
Q

What is the following type of fistula-in-ano?

A

Transphincteric fistula

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27
Q

What is the following type of fistula-in-ano?

A

Intersphincteric fistula

28
Q

What type of fistula-in-ano is the following?

A

Extrasphincteric fistula

29
Q

What type of fistula-in-ano is the following?

A

Suprasphincteric fistula

30
Q

How would you investigate a fistula in ano?

A
  • MRI
  • Endoanal US scan

Rigid sigmoidoscopy, fistulography

31
Q

How would you manage someone with fistula-in-ano?

A
  • Fistulotomy + excision
    • High (transphincteric)- seton suturing tightened over time to maintain continence
    • Low (superficial) - heal by secondary intention
32
Q

Complications of anal fistula

A

Peri-anal abscess

Recurrence

Faecal incontienance post op

33
Q

What are causes of anal ulceration?

A
  • Crohn’s
  • Anal cancer
  • Lymphogranuloma venerum
  • TB
  • Syphillis
34
Q

What is a pilonidal sinus?

A

Obstruction of the natal cleft hair follicles approximately 6 cm above the anus.

In growing hair excites a foreign body reaction and may cause secondary tracks to open laterally, with abscesses extruding foul, smelly discharge

35
Q

So hows a pilonidal sinus different to an abscess?

A

PS open up onto skin but does not continue into anal canal like a fistula.

Distinction formally done by rigid sigmoidoscopy

36
Q

What sex does pilonidal sinuses occur most commonly in?

A

Males

37
Q

Managment of pilonidal sinus

A

Offer hygeine adivce and hair removal adice

Incision and drainage of abscess/sinus (acute)

Recurrence may require wide exciion and ksin flap

38
Q

What percentage fo those with rectal prolapse are incontinent?

A

75%

39
Q

Why does rectal prolapse occur?

A

Lax sphincter, combined with prolonged straining. It is also related to chronic neurological and psycholoigical disorders.

There are two types:

type 1 is the mucosa (partial - loosening and stretching of connective tissue)

type 2 is all layers (defect of fascia in pelvic region eg constipation, chronic cough, multiple vaginal delviery)

40
Q

Presentation of rectal prolapse

A

Incontinence

Perianal symptoms - rectal bleeding

Reduced sphinter tone on DRE

41
Q

How would you manage someone with rectal prolapse?

A
  • Abdominal approach - fix rectum to sacrum (rectoplexy) +/- mesh insertion +/- rectosigmoidectomy (Altmeire’s procedure)
  • Perineal approach - Delorme’s procedure - resect close to dentate line and suture mucosal bouncaries
  • For those unfit for surgery -
    • ​Improve fibre intake
    • Decrease constipation with lactulose
42
Q

What are risk factors for the development of anal cancer?

A
  • Anoreceptive intercourse
  • HPV
  • HIV
  • Increased age, smoking, crohns
43
Q

Where do anal tumours above the dentate line spread to?

A

Pelvic lymph nodes

44
Q

Where do anal cancers spread to if they are below the dentate line?

A

Inguinal lymph nodes

Note 80% are squamous

45
Q

How do those with anal cancer tend to present?

A
  • Bleeding
  • Pain
  • Bowel habit change
  • Pruritis ani
  • Masses
  • Stricture
46
Q

Investigations anal cancer

A

Protoscopy and biopsy

Consider HIV testin

USS guided and fine needle biopsy of any plapable lymph nodes

CT mets, MRI degree of spread

47
Q

How would you manage someone with anal cancer?

A
  • Chemoradiotherapy - radio + flourouracil + mitomycin/cisplatin (external beam)
  • Consider surgery
    • ​Abdominoperineal excision
    • For large lesions - AP resection and colostomy
48
Q

What are haemorrhoids?

A

Disrupted and dilated anal cushions. The anus is lined mainly by discontinuous masses of spongy vascular tissue - anal cushions - which contribute to anal closure. These are prone to disruption and displacement, and can protrude forming piles

Trauma to these piles can lead to leaking of the capillaries of underlying lamina propria

“Abnormal swelling/enlargement of anal vasculature cushions”

PILES ARE NOT VARICOSE VEINS

49
Q

Why are haemorrhoids above the dentate line not normally painful

A

No sensory fibres above the dentate line - not painful unless they thrombose and are gripped by anal sphincter

50
Q

What are causes of haemorrhoids?

A
  • Constipation with prolonged staining - main cause
  • Congestion - pelvic tumour
  • Intra-abdominal pressure
    • Pregnancy
    • Chronic cough
    • Ascietes
    • Obesity
  • Cardiac failure
  • Portal hypertension
51
Q

What is the pathogenesis of haemorrhoids?

A

Vascular cushion protrudes through the tight anus, becomes more congested, and hypertrophy to protrude again more readily. These protrusions may then strangulate.

  • Displacement and dilatation of one or more anal cushions - normally act to asist anal sphincter in maintaining continence
  • BVs become inflammed and swollen
  • Tight anus, more congested so hypetrophying to protrude organ more readily
52
Q

What are symptoms of haemorrhoids?

A
  • Painless bright red rectal bleeding - often coating stools/on tissue/dripping into toilet
  • Mucous
  • Pruritis ani
  • Pain on defication
  • Severe anaemia can occur
  • May be soiling due to impaired continence/mucous discharge

A thrombosed haemorrhoid will present as a purple/blue oedematous, tense and tender perianal mass

53
Q

What features might suggest a more sinister cause of what you initially think are haemorrhoids?

A
  • Weight loss
  • Tenesmus
  • Change in bowel habit
54
Q

Whaat are important aspects of the examination that you need to consider when examining someone with suspected haemorroids?

A
  • Abdo exam - look for sinister pathology
  • PR exam - prolapsing piles, other pathology
  • Protoscopy - visualise haemorrhoids
  • Colonoscopy/flexible sigmoidoscopy if proximal pathology suspected - exclude higher pathology eg malignancy
55
Q

What is classed as a first degree haemorrhoid?

A

Remains in the rectum

56
Q

What is classed as a 2nd degree haemorrhoid?

A

Prolapse through the anus on defecation but spontaneously reduce

57
Q

What is classed as a 3rd degree haemorrhoid?

A

Prolapse on defecation but require digital reduction

58
Q

What is classed as a 4th degree haemorrhoid?

A

Remain persistently prolapsed

59
Q

Where do internal haemorrhoids originate from?

A

Above the dentate line

60
Q

Where do external haemorrhoids originate from?

A

Below dentate line

61
Q

Where do mixed haemorrhoids originate from?

A

Both above and below dentate line

62
Q

How would you manage haemorrhoids?

A

Conservative/Medical - 1st degree

  • High fibre diet + fluids
  • Topical analgesia
  • Stool softeners

95% managed conservatively esp if asymptomatic

Interventional - 2nd and 3rd degree

  • Sclerotherapy
  • Band ligation - haemorrhoid drain into end of a suction gun and a rubber band palced at end, after 10 days
  • Infrared coagulation - in out patient
  • Bipolar diathermy
  • Cryotherapy

Surgical

  • Excisional Haemorrhoidectomy
  • Stapled haemorrhoidopexy
63
Q

Complications of haemorrhoids

A

Strangulation - blood supply to prolapsed haemorrhoid is restricted due to contraction of anal sphincter, resulting in pain and swelling

May become thrombosed, leading to ulceration which is extremely painful.

Skin tags

Perianal sepsis

64
Q

What’s a perianael haematoma?

A

Rupture of perianal subcutaneous blood vessle

65
Q

Presentation of perianal haematoma

A

Perianal pain

Blue/black bulge at anal markin (dark blueberry under skin)

66
Q

Managemetn perianal haematoma

A

Tends to resolve spontaneously

Medical: incision - indicated only for pain releif

Gwen - GI and General surgery (44 decks)

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